Assessment of socio demographic factors on termination of pregnancy in Ghana

Abstract Aim Assessing the socio‐demographic factors on termination of pregnancy in Ghana. Design Cross‐sectional study, using data source from the Demographic Health Survey (DHS). Methods Data pooled from the most recent DHS conducted in Ghana, with variables of interest with rural and urban population coverage. A systematic search of the literature was performed using PubMed, Google Scholar and Elsevier PubMed for the secondary data. Descriptive and logistic regression analysis was performed using Python Pandas' software to estimate the independent effects of the socio‐demographic factors on termination of pregnancy in Ghana. Results Reported using odds and adjusted OR AOR at 95% confidence level and statistical significance at a p‐value of (p > 0.05). Age, place of residence, occupation, currently pregnant, woman's individual sample weight, completeness of current pregnancy, living children + current pregnancy, ethnicity and number of living children significantly predicted the outcome variable. Patient or Public Contribution Nurses have an important role to play in providing support, education and counselling to people, and must be equipped with the knowledge and skills (including non‐judgmental and compassionate care) necessary to provide care that is sensitive to the diverse needs of people from different socio‐demographic backgrounds.

pregnancies and, therefore, may seek ways to terminate them (Bongaarts, 1997).Between the years 2010 and 2014, about 55.7 million terminations of pregnancies in the form of abortions occurred annually worldwide, where 88% of them were from developing countries (Ganatra et al., 2017).A newly released model of estimates for pregnancies and abortions in the world shows that some 266,000 abortions were done in Ghana within four years from 2015 to 2019 (Ghana Business News, 2022).

| BACKG ROU N D
Maternal mortality is the second most common cause of death among women in Ghana, and more than one in 10 maternal deaths (11%) are the result of unsafe induced abortions (Ghana Statistical Service, Ghana Health Service, & Macro International, 2007).
Pregnancy termination can happen in the form of abortion, miscarriage, menstrual regulation and stillbirth.The rate at which pregnancies are terminated has remained high in middle and lower-income countries (MLIC'S) around the world, and this reflects a trend of mistimed, unwanted and unintended conceptions (World Health Organization, 2016).According to Haddad and Nour (2009), of the millions of women who terminate an unintended pregnancy each year, approximately half are recipients of an 'unsafe' intervention; unsafe abortions are performed by unskilled individuals in environments that do not meet medical standards.Religion and spirituality also play a very important role in the youths' attitudes toward termination of pregnancy.According to Selebalo-Bereng and Patel (2019), Muslims reported greater disapproval than other religious groups.
They also found out that Christian youth had the most negative attitudes to pregnancy termination for 'Traumatic reasons' and 'When women's health/life' was threatened.This invariably generates a lot of concerns for maternal healthcare, especially among women of reproductive age in the MLIC's.
In Ghana, termination of pregnancy remains a major public health challenge despite the apparent liberalization of the law on abortion over two decades.Although termination of pregnancy in Ghana is legally permissible, it can only be conducted at a government hospital; registered private hospital, clinics registered under the Private Hospitals and Maternity Homes Act, 1958 (No. 8) and a place approved by the Minister of Health by a Legislative Instrument.The contention is that the current law on abortion makes enforceability difficult and leaves room for untrained personnel to engage in dangerous abortion procedures and that there is a need for law reform (Morhee & Morhee, 2006).
In Ghana, termination of pregnancy has gained appreciable attention in reproductive health discussions (Lithur, 2004).This is surprising given the country's restrictive laws, which permit abortion only in instances where conception is the result of defilement, rape, or incest or if pregnancy poses a threat to the health of the woman (Lithur, 2004).
A couple of studies have identified socio-demographic factors that are associated with pregnancy termination in developing countries, and these include age of the women, marital status, educational level, employment status and total number of children.
These factors have significantly been associated with an increased risk of pregnancy termination (Adjei et al., 2015;Arambepola et al., 2016;Dankwah et al., 2018;Maina et al., 2015).According to Dankwah et al. (2018), women who are employed, cohabit with a partner, have intermediate levels of education, and are considered middle-class or wealthy are more likely than their counterparts to report having terminated a pregnancy.Klutsey and Ankomah (2014), indicated that marital status, employment status, number of total pregnancies, and knowledge about contraception were found to be associated with induced abortion.They did not, however, find any relationship between pregnancy termination and maternal age, education, contraceptive use, or religion.women who are capable of taking reproductive health decisions, age, level of education, contraceptive use and intention, place of residence and parity are associated with pregnancy termination (Seidu et al., 2020).
According to Ahinkorah et al. (2021), the socio-demographic determinants of pregnancy termination among AGYW are age, level of education, marital status, exposure to radio and television, parity and community literacy level.The findings provide the needed information for designing health interventions to reduce unwanted pregnancies and unsafe termination of pregnancies in countries with high-fertility rates in SSA.
Termination of pregnancy exhibits diverse forms of risk that include secondary infertility, ectopic pregnancy and foetal loss increase (Hogue, 2008).Studies have consistently shown that induced abortion increases the incidence of subsequent preterm delivery and depression (Thorp et al., 2003), which can ultimately affect a woman's decision to have more children in the future.Pregnancy termination has therefore been found as one of the key issues that need to be addressed to attain Sustainable Development Goal 3 by 2030 (Manandhar et al., 2018).

| Design
A cross-sectional study was used in collecting data at a single point in time from a sample of individuals representing the population of interest.

| Method
Existing data sources, the DHS national survey, were used to identify a sample of women who have undergone termination of pregnancy to collect data on their socio-demographic characteristics, such as age, ethnicity, education level, income, marital status and residence.Data was pooled from the most recent DHS conducted in Ghana, including all the variables of interest which had the coverage for both rural and urban populations.Permission to utilize these data sets was granted after registering with the DHS programme manager.A systematic search of the available literature was performed in September to December 2022 using the following databases: PubMed, Google Scholar and Elsevier for the secondary data.The search strategy was to determine search concepts and types of studies on the topic.The keywords (and their combinations) adopted for the manuscript are the following: socio-demographic factors and termination of pregnancy.Separate searches for each primary database combined subject headings, terms and key text words with the Boolean operators (AND) and (OR), accordingly.All eligible pregnant women between the ages of 15 and 49 selected for the individual were used for the study.The socio-demographic variables included age, residence, currently working, religion, highest educational level for both woman and husband, wealth index, husband partner occupation, religion and ethnicity as independent variables or determinants used as predictor variables.

| Analysis
The socio-demographic factors among pregnant women of reproductive age 15-49 years were examined and analysed.Sociodemographic factors associated with termination of pregnancy were identified by estimating binary and multivariable logistic regression models.Non-pregnancy termination was used as the reference group or baseline for the analysis.The datasets were carefully checked for missing values, which were excluded and weighted with the appropriate sampling weights as per the DHS sampling scheme.Three levels of analyses (univariate, bivariate and multivariate) were employed.At the univariate level, descriptive statistics related to the characteristics of the study population and socio-demographic factors were generated through frequency and percentage.Using the Pearson chi-square test, unadjusted binary logistic regression analyses were adopted at the bivariate level to investigate the independent effect of each explanatory variable on the outcome variable.Chi-square tests were performed to assess differences in categorical variables.Two models of multivariable logistic regression were performed to assess the relationship between socio-demographic and other variables on termination of pregnancy.Women were asked whether they had ever experienced termination during pregnancy, and if so, what led to it.Additionally, women were asked whether they had ever had a pregnancy loss as a consequence of their pregnancy at the multivariate level.Binary logistic regression models were used to measure the odds ratio (OR) of the association between socio-demographic factors as the explanatory variables on the outcome and termination of pregnancy.
The unadjusted and adjusted binary logistic regression analyses of the association between socio-demographic and termination of pregnancy were carried out at the multivariate level.Possible associations between each of the explanatory variables and the outcome variable were assessed by observing the p-values.The results of the explanatory variables were expressed as OR with 95% confidence intervals.

| Ethic s
Since it was a study using secondary data ethical approval was not required.

| RE SULTS
5 ethnic groups in Ghana on termination of pregnancy are presented in Table 1.Education in the multivariable logistic regression".This suggests that having a higher level of education is negatively associated with the outcome variable.In terms of the relationship between education and pregnancy termination, higher education may expose women to the risks associated with pregnancy termination and hence may reduce their involvement in them.On the contrary, a study in China by Geo et al. (2019), found pregnancy termination to be high among women with higher educational levels and argued that educated women may have pregnancies that interfere with their education and hence may decide to terminate those pregnancy.The other groups, "Primary" and "Secondary", have OR >1, indicating that these groups are positively associated with the outcome variable.

| Descriptive statistics
With a husband partner education secondary education level had higher odds of terminating pregnancy, this indicates that women with husbands with secondary educational background were more likely to terminate their pregnancies compared to the reference category of no education.This confirms the works of Ahinkorah et al. ( 2021), who found out that the educational level or partner education influences termination of pregnancy.
The study found that the urban place of residence is the one that is predicting the outcome variable with the highest OR.This finding agrees with other works which state the likelihood of pregnancy termination was lower among young women who lived in rural areas as compared to those in urban areas (Adjei et al., 2015;Seidu et al., 2020).
The study has shown that "respondent currently working" predicts the outcome variable with the highest OR.In terms of wealth index, "Richer" and "Richest" levels of Wealth Index have a stronger association with the outcome variable.This suggests that these levels of Wealth Index may be good predictors of the outcome variable.With current marital status "Living with a partner" and "No longer living together/Separated" marital statuses have the largest positive effect on the outcome variable when compared to the reference category "Never in union".This is to say that "respondent currently working", Wealth Index and marital status are predictors of termination of pregnancy.This confirms the work of other researchers (Ahinkorah et al., 2021;Klutsey & Ankomah, 2014).
Using the multivariable logistic regression to analyse religion, the study found that in terms of religion practice, traditionalist religion are more likely to have a positive outcome, Christianity is less likely to have a positive outcome, for Islam is relatively close to zero, indicating that the effect of this religion on the outcome variable may be minimal.This agrees with a study in South Africa that reveals that religion play a role in the youths' attitudes towards abortion.
While the Hindu subsample indicated higher overall support across the different scenarios, the Muslim subsample reported greater disapproval than the other groups on 'Elective reasons' and in in-

| Limitations
The analysis has strengths and limitations; one of the strengths is the large sample size, which could be a representativeness of other women of reproductive age group in the general population, and thus making the result generalizable.The DHS dataset is standardized and validated, eliminating information bias.The limitation of using secondary source data is subject to missing important information (Variables) and recall bias.

| CON CLUS ION
The results indicated that age, type of place of residence, respondents' It is therefore highly recommended that the government and other health-related agencies should focus more on reproductive health programmes targeted at those who are at risk of pregnancy termination as such programmes will contribute to attaining sustainable development goal 3, that seeks to reduce maternal mortality by 2030.
Data was analysed using Python Pandas.Weights were applied to all the descriptive statistics using women's individual sample weight (v005) for the individual recode model.Descriptive statistics were used to summarize the proportion for categorical variables, unadjusted and AORS with 95% confidence interval (CI), estimated in a logistic regression to identify the determinants of termination of pregnancy and a number of explanatory variables at a p value of <0.05 considered statistically significant to assess and strengthen the association.The final selection for inclusion criteria in the final logistic model was based on a significant association of sociodemographic factors and effects on termination of pregnancy.
stances of 'Objection by significant others.'The Christian youth had the most negative attitudes toward abortion for 'Traumatic reasons' and 'When women's health/life' was threatened (Selebalo-Bereng & Patel, 2019).Individuals with five or more living children have higher odds of having a certain outcome compared to individuals with 0 living children, which is the reference group.
occupation, currently pregnant, woman's individual sample weight, completeness of current pregnancy, living children + current pregnancy, ethnicity and number of living children are significant predictors of termination of pregnancy.The study also confirms that improvement in education and eradicating poverty would be an important policy intervention to increase the reduction of pregnancy termination.The findings of the study also provide the needed information in designing health interventions in reducing termination of pregnancy.
Table1describes the ethnic groups in detail with their frequencies and percentages of pregnancy termination.The prevalence of pregnancy termination in each of the ethnic groups in terms of weighted percentage ranged from 1.9% (other ethnic groups) to 44.0% (Akan).Socio-demographic characteristics of women of reproductive age.Binary and multivariable logistic regression model.Multivariable logistic regression indicating levels predicting outcome variables highly.
trimester, currently working 6761 (72.0%),Uncompletedness of current pregnancy information 8717 (92.8%), no living children + current pregnancy 2805 (29.9%).The results ofTable 3 are from a logistic regression analysiswhere the outcome variable is "Ever had terminated pregnancy."The model converged successfully with a final function value of 0.47 and TA B L E 2 9.3% of the variation in the outcome variable.Reporting on the OR of the binary logistic regression.The coefficients (coef) and standard errors (SE) of the independent variables are also provided.The p-value (p > |z|) is used to determine the significance of the variable in the model.A p-value of <0.05 is considered significant.From the results, it appears that age in the 5-year group, type of place of residence, respondent occupation, currently pregnant, woman's individual sample weight, completeness of current pregnancy, living children + current pregnancy, ethnicity and number of living children are significant predictors of the outcome variable.The other variables have p-values >0.05, indicating that they are not significant predictors of the outcome variable.Socio-demographic variables predicting termination of pregnancy in Ghana, that have the highest coefficients and the lowest